Case Study: Physiology Of Infected Laceration Wound And Treatment Procedure

Mary, 21 years old, presented to the hospital emergency department with an infected laceration on her left foot. Mary was at a beach resort four days ago, when she trod on a broken glass bottle and sustained a deep 2 cm long jagged laceration over the lateral aspect of her left foot. She used her handkerchief to bandage the wound. This morning the wound was extremely painful, swollen and had a purulent discharge. 

On inspection of the wound the following wound observations were made: 

— Painful and swollen. — Red and warm when touched. — Purulent discharge.

Exploring the physiology of the laceration.

Patient history and wound observations

This case study represents the case of a 21 years old young woman named Mary who had presented to the emergency department with the compliant of an infected laceration on her left foot. The patient described the origin of attaining the wound in a beach resort 4 days ago where she stepped on a broken glass bottle and attained a deep 2 cm long jagged laceration over the lateral aspect of her left foot. The patient further informed that after attaining the wound in the beach she used her handkerchief to cover the wound and stop bleeding. The patient mentioned that as she woke in the morning that day, her laceration wound was extremely painful, swollen, and also had a purulent discharge.

Exploring the physiology of the laceration can be defined as a torn or jagged wound which is generally caused by sharp objects (Theoret, 2016). Laceration is a type of wound that causes irregular wound, and as the wound that the patient attained was 2 cm long and has the chances of seeping into the subcutaneous tissues including underlying muscle, internal organs, or bone. Such laceration wounds are accompanied by pain and significant bleeding. It has to be mentioned that the most important course of action in case of laceration wounds are to terminate the bleeding using sterilized techniques. In this case, the patient used her handkerchief to bandage the wound which can be a contaminated piece of clothing transferring bacteria to the wound and facilitating the infection of the laceration wound, which had been the case for the patient in the case study as well (Wroblewski, Siney& Fleming, 2016).

The observations of the wound had been painful and swollen, appearing red and warm to touch, along with having a purulent discharge. It has to be mentioned that inflammation is the most common clinical manifestation of infection which is generally localized to the wound tissue. The redness observed in the wound and the surrounding tissue is generally concerned as the normal inflammatory process of the wound healing, however for persistent and expanding redness indicated infection progress under the tissue. Along with that, the purulent discharge or pus discharge is a tell-tale sign of infected wound (Harper, Young &McNaught, 2014). This purulent discharge, also known as Liquor puris, is the protein rich fluid that is whitish-yellow or brown-yellow in colour that accumulates at the site of infection as a result of the process of pathogenic proliferation. Lastly, the wound was also appearing warm to touch which indicates that the innate response of the immune system of the body to fight the infection that has occurred.

Understanding the physiology of laceration wound

Exogenous contamination is one of the most common type of contamination that is reported to infect the wound sites. The most common exogenous pathogen that can infect the laceration wound as depicted in the case study is Pseudomonas aeruginosa. It has to be mentioned that the patient had sustained this wound while walking on the beach and had used her handkerchief to bandage the wound. Hence, it can be stated that the wound was properly bandaged and was exposed to the microbiota and causing the infection. P.aeruginosais a very common pathogen that causes wound infections very commonly (Serra et al., 2015).

Pseudomonas aeruginosais a very common gram negative, opportunistic bacteria that causes severe acute infections, specially causing wound and burn infections. It is an opportunistic and ubiquitous bacteria that is found mostly in soil and water. It has to be mentioned that the patient had been on the beach while she attained this wound and used the handkerchief that she had been using while spending her day at the beach. Hence, it is very easy for the pathogen to infect the wound via direct transmission by either the infected glass bottle or the though the handkerchief she used to bandage the wounds (Serra et al., 2015). For new host, the infection can be facilitated by direct contact via the hands of the care staff in case they are not following the hand hygiene protocol properly (Marieb & Hoehn, 2016).

Endogenous pathogens are the microflora that are found in the body of the humans that can opportunistically cause infections (Lee & Bishop, 2012). The most common type of endogenous pathogen which is known for causing the endogenous infections, especially the wound infections is the Staphylococcus aureus. This is most common pathogenic bacteria found to inhabit the human skin and can easily infect any wound site by invading the tissues via the broken skin (Krezalek et al., 2018).

The mode of transmission for this pathogenic bacteria is the direct contact mode of transmission. Anyone coming in direct contact with the wound of the patient will be the likely host for the bacteria to contaminate, hence the health care staff caring for Mary are at risk for infection. Along with that, anyone coming into contact with the supply material or equipment that have been used for Mary and have not been sterilized can acquire the infection as well (Krezalek et al., 2018).

The regular treatment for wound infection begins with antibiotics, generally broad spectrum and with higher plasma half-life to ensure optimal efficiency against the infection. Ceftriaxone is a very commonly used broad spectrum antibiotic that is produced from Cephalosporiumacremonium (Craft et al., 2015). This particular antibiotic has a considerably higher plasma half-life and is also very effective against a broad range of pathogens (Anand, Batra, Arora, Atwal &Dahiya, 2016). Hence, it is the most common choice of antibiotic which was given to Mary and it is most effective in intramuscular IV administration hence a stat dose of IV ceftriaxone was given to Mary.

Exogenous and Endogenous pathogen

In case wound infection treatment, the initial administered of IV antibiotic is followed with a milder oral antibiotic. Cephalexin is a common mild oral antibiotic belonging to the class of cephalosporin. It is a systemic antibiotic prescribed for skin infection, wound infection and ear infections (Dalen, Fry, Campbell, Eppler& Zed, 2018). This mild antibiotic mimics the mechanism of action of penicillin stopping the growth of the pathogen by disrupting the cell wall production of the bacteria, hence it has a very effective bacteriostatic action, and hence, was administered to Mary.

The most common type of wound or skin infections are caused by strains of Staphylococcus, which is mostly resistant to cephalosporin group of antibiotics. In this case, the wound observations indicated the infection being caused by S. aureus. Hence, cephalexin was discontinued for Mary and dicloxacillin was administered which was also gold standard antibiotic to be used for staph infections (Nissen et al., 2013).

Adverse reactions are heartburn and diarrhoea.

Wound healing can be defined as a complicated process recruiting 4 distinct cell types, it is a continuous process that is completed in phases, namely coagulation, inflammation, proliferation, and remodelling. However, the healing procedure depends on various different factors pertaining to the physiology of the wound.The first stage is coagulation that begins with the platelets and corpuscles rushing to the bleeding areas and forming blood clots to stop bleeding (Golebiewska& Poole, 2015). In the next phase, inflammation takes place that clears out the damaged cells and pools nutrients in the wound area removing the debris and bacteria, followed by deposition of collagen granules. The next phase is contraction of the wound which will lead to repair and remodelling of the wound tissues. In this phase the deposited collagen tissues are remodelled and aligned along the tendon lines closing the broken tissues and completing the healing process (Bullock & Manias, 2017). However, the occurrence of infection slows and complicates the healing process which takes close to 10 days to completely heal (Darby, Laverdet, Bonté&Desmoulière, 2014). With the aid of antibiotic therapy the infection in Mary’s wound will easily be eliminated and as dicloxacillin which is very effective against S. aureus, infection will be adequately managed by the bacteriostatic activity of dicloxacillin and wound will heal effectively within 5-8 days.

References:

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Bullock, S & Manias, E. (2017). Fundamentals of Pharmacology (8^th edition) French forest , Austrlai: Pearson Australia

Craft, J., Gordon, C., Huether, S. E., McCance, K. L., & Brashers, V. L. (2015). Understanding pathophysiology-ANZ adaptation. Elsevier Health Sciences.

Dalen, D., Fry, A., Campbell, S. G., Eppler, J., & Zed, P. J. (2018). Intravenous cefazolin plus oral probenecid versus oral cephalexin for the treatment of skin and soft tissue infections: a double-blind, non-inferiority, randomised controlled trial. Emerg Med J, emermed-2017. Doi: 10.1136/emermed-2017-207420

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Lee, G., & Bishop, P. (2012). Microbiology and infection control for health professionals. Pearson Higher Education AU. Retrieved from: https://books.google.co.in/books?hl=en&lr=&id=qhTiBAAAQBAJ&oi=fnd&pg=PP1&dq=microbiology+and+infection+control+for+health+professionals+Lee&ots=hxQ7f6LZ-a&sig=RawVyNsKPSO_Q5MGLvvqtHYtSvc#v=onepage&q=microbiology%20and%20infection%20control%20for%20health%20professionals%20Lee&f=false

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